Stanford University School of Medicine and the Predecessor
Schools: An Historical PerspectivePart III. Founding of
First Medical School and Successions 1858-

Chapter 18. Professor Elias S. Cooper, University Surgeon

An Evaluation

John Bell (1763-1820) was a famous Edinburgh anatomist and
surgeon, and one of the founders of vascular surgery, a field in
which Dr. Cooper had a special interest. Bell introduced his
classical monograph on The Principles of Surgery in 1801 with the
following reflections on the evaluation of surgeons:[1]

In every profession, the daily and common duties are most
useful; and in ours, the man who is capable of the great
operations rises into public esteem, only because it is presumed,
that he who is most capable in the higher departments of his
profession will best perform all its ordinary duties. .
.(Accordingly), operations have come at last to represent as it
were the whole science; and a Surgeon, far from being valued
according to his sense, abilities and general knowledge, is
esteemed excellent only in proportion as he operates with skill.

We shall in due course show that Cooper was not only
"capable of the great operations," but that he also drew upon his
extensive surgical experience and laboratory experiments to make
significant observations. It is these distinctive contributions
that qualify him to be regarded as a "University Surgeon" in the
modern sense, and set him apart from all other surgeons on the
Pacific coast in his era.

Before proceeding with our evaluation, we should point out
that Cooper's numerous publications in the medical literature are
our major source of information on his achievements as a surgeon.
Since a list of his papers had never been assembled, we searched
the journals of his day and compiled a Bibliography of 139
original articles and commentaries. From these we will now draw
some conclusions as to the significance of his surgical work,
keeping in mind of course the state of the art at the time.

Many of Cooper's articles were accepted for publication in such
well-known journals in the east as the American Journal of Medical
Sciences (Philadelphia), Medical and Surgical Reporter
(Philadelphia), American Medical Gazette (New York, American
Medical Times (New York), Cincinnati Lancet and Observer, St.
Louis Medical and Surgical Journal, Chicago Medical Journal and
North-Western Medical and Surgical Journal (Chicago). Not only did
this general acceptance of his papers indicate an interest at the
national level in his case reports and ideas, but also assured
them of wide dissemination. The recognition thus gained by Cooper
was especially galling to the venomous Wooster who had unwittingly
impelled him onto the national stage of medical literature by
denying him access to the Pacific Medical and Surgical Journal. In
the following editorial in the June 1861 issue of the Journal,
Wooster sought to discredit Cooper with the editor of the American
Medical Times, hoping that he and other eastern editors could be
induced to refuse Cooper's manuscripts.[2]

The American Medical Times must have an intense desire to
gratify its readers with original matter from remote sources. We
are led to give this hint at seeing a California communication in
the number of May 25th 1861, and also one in that of June 1st.
The status of the author is so low here, socially and
professionally, that we cannot imagine how the editor of the
Times will lend himself to bolster up such an advertising
pretender. Medical journals cannot ignore this allusion, for we
definitely proved it to the profession some two years since. (
Pacific Medical and Surgical Journal 1859 Dec; 2 (12): 495-499)

The editor of the Times ignored the Wooster libel and
continued to publish papers submitted by Cooper, as did other
eastern editors.

We shall begin our assessment of Cooper's professional
stature by calling attention to his technical proficiency and
follow with comment on the exceptional range and complexity of the
operations that brought him the "public esteem" to which John Bell
referred. We shall then mention some of his noteworthy experiments
in the animal laboratory before, finally, identifying certain
surgical principles that he derived from personal experience, and
for which he claimed priority.

Master Surgeon

There can be no doubt from the operations we have already
described and the regional acclaim to which we have previously
alluded, that Cooper was a fearless and skillful surgeon, with a
self-assurance born of natural aptitude and intensive anatomical
study. Incredibly, he was almost entirely self-taught. Levi Cooper
Lane, a not impartial witness, assisted his uncle during many
operations and was in awe of his surgical prowess:[3]

As an operator, he manifested, in a pre-eminent degree,
that cool daring, that deliberate self-possession, - which the
most untoward circumstance, so far from disturbing, seemed only
to increase, - that instant comprehension of the difficulties
which happen to arise during an operation, and that intuitive
readiness to surmount them, which are the essential elements of
great and original surgical genius. Not only was he
self-possessed himself, but his manner was such as to thoroughly
inspire his patient with the most perfect confidence that he was
wholly secure in his hands; and of his spectator, no one who saw
with what perfect ease the chisel and drill moved in his hand
during his exsections, and the use of the silver ligature for
ununited fractures, or with what rapidity, at one bold sweep, he
deeply divided the structures of those regions of the body which
most surgeons approach with caution, but who, in the one case,
were thoroughly impressed with the superiority of his mechanical
talent, and in the other, that his daring celerity could only be
founded upon that accuracy of anatomical knowledge, which
rendered the tissues, as it were, transparent under his eye. I
think that no one, who ever stood by his side at such a time,
feared for a moment, that the operation would not end
successfully.

Such a paean from an experienced observer, albeit a biased one,
leads us to conclude that Cooper was indeed an accomplished
surgeon. For him, surgery was a true vocation. He was undaunted by
the stress and complexity of difficult operations and he had the
rare gift of responding to technical challenges by improvised
measures. According to Dr. Lane, Cooper once remarked that at no
time had he been happier than when, during an operation, some
grave unforeseen complication arose which threw his mind wholly on
its own resources, and for surmounting the difficulty compelled
him to rely upon the suggestions of the moment.[4] We recall, for example, his
remarkable extraction of a slug of iron from behind the heart of
B. T. Beal with a special instrument; the control of major
hemorrhage by ligating both iliac artery and vein in Frank
Travers; and suture of the uterus to control bleeding during Mary
Hodges' cesarean section. In all these operations Cooper made
innovations, and they were life-saving.

Great Operations

The extraordinary scope of Cooper's operative experience is
readily apparent from a scanning of his bibliography. He was
capable of performing the most advanced procedures then being
undertaken in the fields of ophthalmic; head and neck; thoracic;
abdominal; orthopedic; and vascular surgery. Since his
bibliography refers specifically to many of these operations and
we have already described certain of them, we shall limit our
further consideration of this subject to pointing out that Cooper
performed, on two occasions in each, the most difficult and
controversial operations in the surgical armamentarium at
mid-century. These procedures were caesarean section and ligation
of the innominate artery. We have already reported amply on
Cooper's two caesarean sections and their outcome.

Ligation of the Innominate Artery

We have not, however, previously mentioned that he twice
ligated the innominate artery. This artery, the first and largest
branch of the aortic arch, ascends to the thoracic inlet where it
divides behind the upper sternum into the right common carotid and
subclavian arteries. These vessels are the main blood supply to
the right side of the head and the right upper extremity. Aneurysm
(i. e., circumscribed dilatation) of the innominate, carotid
and/or subclavian arteries may occur at the bifurcation of the
innominate, usually as the result of trauma or arteriosclerosis.
Unless successfully treated, death from spontaneous rupture of
aneurysm in this location is a near certainty.

At present, such aneurysms may be removed and replaced by
synthetic vessels without undue risk. However, when Cooper
practiced, the treatment consisted of ligating the innominate
artery, a procedure considered the most formidable operation of
that day. Valentine Mott (1785-1865), Professor of Surgery at
Columbia College of Physicians and Surgeons in New York, was the
first surgeon, world-wide, to ligate this vessel for aneurysm with
survival of the patient. He performed the procedure on a
fifty-seven year old sailor at New York Hospital on 11 May 1818.
The only "anesthesia" administered was a drink containing seventy
drops of tincture of opium. The operation occupied about one hour.
Although the patient died of secondary hemorrhage on the
twenty-fifth postoperative day, the case established the
practicability of the operation. For that reason it was acclaimed
throughout medical circles in Europe and America. In consequence
of this operation, Professor Mott attained an international
reputation by the thirty-fourth year of his age. As predicated by
John Bell's postulate, Professor Mott is best remembered to this
day for the great operations he performed, particularly his
ligation of the innominate.[5][6]

During the forty-year period from 1818 to 1858, eleven surgeons
from around the world, including Professor Mott, succeeded in
ligating the innominate artery. The outcome was the same in every
case - the patient died.[7]

In March 1859, Cooper was consulted by a man with a combined
aneurysm of the right common carotid and subclavian arteries.
Ligation of the innominate artery was the only known treatment for
his condition. Undeterred by the knowledge that all eleven of the
previous operations had been followed by death of the patient,
Cooper decided to operate. He had the advantage of general
anesthesia which had not yet been discovered when nine of the
previous cases were done. During the operation, Cooper removed the
medial end of the clavicle and a portion of the upper end of the
sternum to improve the exposure, this being the first time this
valuable maneuver was employed during ligation of the innominate.

The procedure went well and the vessel was tied off with
minimal blood loss. Postoperatively, the patient was comparatively
comfortable for five days. After that time he became restless,
short of breath, and unable to void. He gradually sank until the
ninth day when he died. An autopsy was done and failed to reveal
the cause for the patient's rapid decline after an initial period
of satisfactory progress. The major causes of death after ligation
of the innominate in past cases had been severe wound infection
and exsanguinating hemorrhage. Neither of these conditions were
present in Cooper's patient. Since the patient had developed
anuria postoperatively, Cooper believed renal failure to have been
the cause of death rather than anything directly related to the
operation. It was a tantalizing thought that, except for this
unforeseen and unrelated circumstance, success would have crowned
his efforts and the acclaim for a truly "great operation" would
have been his.

Cooper's disappointment in the outcome was reflected in the
brevity of his report on the operation which he mailed to the
editor of the American Journal of Medical Sciences on 20 March
1859. His perfunctory description of the case, only a page and a
half in length and lacking many relevant details, was published in
the October 1859 issue of the American Journal.[8]

Cooper thought that he had done his duty by simply reporting the
failure of the ligation, and that the case was closed. He was
therefore quite unprepared for the harsh rebuke he was soon to
receive from his former colleague and friend, Professor Daniel
Brainard of Rush. As editor-in-chief of the Chicago Medical
Journal, Brainard utilized the pages of the December 1869 issue of
the Journal to attack Cooper for his temerity in undertaking the
ligation, and for reporting the case so incompletely. Professor
Brainard was quite stern:[9]

The October number of the American Journal contains a
report of a (ligation of the innominate), if report it may be
called, which omits nearly every important fact connected with
the history of the case, the seat and extent of the disease, its
effects, etc. . .

We notice this operation, to say that it is one which
cannot receive the approbation of any judicious surgeon. Ligature
of the arteria innominata had been performed (eleven) times
(previously). In all the result was fatal. . .

Cases of this kind, published without comment, and thus
partly endorsed by journalists, have given rise to the term
"audace Americaine," used by Trouseau. If editors, in giving
currency to this and similar reports, would express their
opinions of the propriety of such operations, it is likely that
fewer would be done, and the responsibility be thrown upon the
individuals who, without any prospect of benefit to their
patients, think fit to resort to them.

We know of Cooper's high regard for Professor Brainard who had
been his mentor and paragon in times past, but the Professor's
public attack on his competence, judgement and integrity was
intolerable. Soon after he acquired his own editorial voice in the
San Francisco Medical Press, Cooper responded to Brainard with a
Commentary in the July 1860 issue of the Press:[10]

Nothing we commend more than just criticism even when
touching the faults of our own performances, and such critique
would have to be very severe indeed if we did not take it in good
part with the writer.

Our report, as published, of the operation (mentioned in
your editorial), was justly obnoxious to severe criticism, partly
owing to our own carelessness and partly that of our Amanuensis;
so much so that we were really chagrined on seeing it in print
with so many imperfections. . . But a critique above all other
productions is expected to be free from faults. (Your editorial),
however, is not one of that kind. In addition to special pleading
against the operation of ligating the arteria innominata under
any circumstances, based solely upon assertion and individual
authority, there are forced conclusions which show much more of a
disposition to criticize, than industry in preparing for the
same. . .

For the editor of the (Chicago Medical Journal) to say that
no judicious surgeon would perform that operation, without giving
any reasons for the statement, when Mott (and ten other) eminent
(surgeons) thought proper to operate, is arraying individual
opinion against an amount of authority which we conceive to be
very bad taste to say the least. Why should not a judicious
surgeon operate? Is it because patients demanding it (as is
conceived) could ever recover without? No; every one would die at
no distant period

We can readily imagine a case in which it would be very
injudicious to operate. Take for instance a small aneurysm
growing very slowly, especially in an old person. But such has
not been the case with those upon whom the operation has been
performed.

Surgeons will differ in opinion in regard to the propriety
of hazardous operations in hopeless cases. Occasionally the
wishes of a patient might rightfully have much to do with
deciding whether to operate or not. . .

Again, the idea that a French surgeon would apply to
American surgery the term "Audace Americaine," is or ought to be
regarded as simply ridiculous by one who has ever witnessed much
practical surgery in the Parisian hospitals. Everybody knows who
knows anything of the matter, that no surgeons in the world
operate upon more hopeless cases than those of the French
Hospitals.

In his caustic response to Brainard's reproach, Cooper made
it clear that he believed ligation of the innominate to be a
justifiable operation under proper circumstances. Within a few
months he had an opportunity to act on this conviction.

On 23 September 1860 a 31 year-old man, otherwise in
excellent health, was admitted to the Pacific Clinical Infirmary
with a large aneurysm of the right subclavian artery filling the
entire supraclavicular triangle. On September 30th Cooper operated
and for the second time ligated the innominate artery. As in his
previous case he resected the medial end of the clavicle and a
portion of the upper end of the sternum to gain the necessary
exposure.

The operation was at once the subject of intense interest to the
American profession. Cooper received a barrage of letters and made
the following progress report to the editor of the American
Medical Gazette (New York) on 30 October 1860:[11]

Today is the 30th day (since I ligated the arteria
innominata), and the patient has every prospect of recovering, so
far as could be judged by any other evidence than that based upon
the results of past experience of other surgeons. . .

On the 20th day after the operation a most violent
hemorrhage began, but was arrested at once by the promptitude of
a medical student. . . I do not permit myself to hope that the
case will terminate favorably; but still the patient is vigorous,
cheerful, has a good appetite, sleeps well, laughs and talks to
his friends, and declares that he will live, notwithstanding he
has been informed that no other ever survived this operation.

Cooper's next, and last, progress note on this patient was
published in the January 1861 issue of the San Francisco Medical
Press:[12]

To the inquiries of several medical friends, in regard to
the recent ligating of the Arteria Innominata, we would state,
without further answer, that the patient died on the forty-first
day. A slight hemorrhage occurred on the (20th), but not again
until the 39th day. The bleeding (on this last occasion) stopped
without any interference. On the next day, it began with
considerable violence being difficult to arrest. The day
succeeding, it was found impossible to prevent bleeding although
we had invented an apparatus which pressed with much force
directly upon the bleeding surface, and controlled the hemorrhage
far better than any compress and bandage.

At three P. M. of that day, the patient was informed that
all hope of recovery was lost, but that he had remaining a
sufficient length of time to arrange his earthly matters. He
expressed no wish to use the time in that way, and, as soon as he
was alone, forcibly removed the apparatus, and bled to death at
once.

From his vantage point as editor of the Pacific Medical and
Surgical Journal, Wooster had kept a watchful eye on Cooper's
every move, and saw in this case an opportunity to revile him:[13]

California is not behind any portion of the world in the
art of crime. She is equal to other portions of the world in arts
and science and experiment, quoad the ability. She merely lacks
the development.

The arteria innominata has been tied in this city and the
case is dead, and the autopsy has been made. Result: he died from
the effects of the operation. Any surgeon who ties the innominata
is either insane, a knave, or ignorant of hydrodynamics. This
operation is necessarily fatal, as any physicist can demonstrate,
without recourse to physiology. The ligation external to the
tumor is rational, and should be sometimes successful.

Cooper's definitive report on his second operation finally
appeared in the August 1861 issue of the Cincinnati Lancet and
Observer. He gave details of the operation, postoperative course
and autopsy. In this case, and presumably also in the first, the
innominate artery was tied with "four strands of saddler's silk."
In accordance with standard practice at the time, the ends of the
silk at the knot were left long and brought out through the wound.
Due to the inevitable wound infection, the tie around the artery
gradually eroded entirely through the vessel and was then drawn
out of the wound by traction on the long ends. In this second case
the detachment of the ligature occurred on the eighteenth day. As
might be expected, hemorrhages began shortly thereafter for the
ligature had completely divided the artery and the force of the
blood pressure expelled the clot that temporarily occluded its
lumen.

The failure of early operations for ligation of the
innominate was generally the result of ligatures cutting through
the artery because of infection. For that reason, frequent success
of the operation was not achieved until well into the aseptic era.
Only then did it become possible, because of the sterile operating
field and primary wound healing, to ligate the innominate with
ligatures that remained permanently in place and did not slip off
or cut through the vessel.

Cooper was devastated by the terrifying hemorrhages and fatal
outcome of his second case. The patient's robust physical
condition, the technical precision of the operation, and the
prolonged postoperative survival had filled him with hope His
report concludes with the following disconsolate thoughts:[14]

This case, more than any other that has yet occurred in my
practice, made the strongest impression on my mind. Never before
have I felt so humiliated by the inefficiency of the surgical art
in rescuing patients from death. What are we to do with such
cases? Is there no new process for treating these aneurysms more
available than any yet established, and can the skill of the
whole surgical world avail nothing? Time will prove. . .

I write for those who are inexperienced, because having had
two cases terminating in the same way, I never expect to have
more experience upon the subject, and would fain benefit those
who are disposed to, but have not yet tried, this most hazardous
of all operations upon the arteries.

The first surgeon, ever, to report long-term survival after
ligation of the innominate artery was Andrew Woods Smyth at the
Charity Hospital in New Orleans. On 15 May 1864, just four years
after Cooper's second case, Dr. Smyth ligated the right common
carotid and the innominate for an aneurysm of the right subclavian
artery in a 32 year-old mulatto man. Thirteen days after operation
the carotid ligature came away and on the fourteenth the first of
several self-limiting hemorrhages occurred. On the sixteenth day
the innominate ligature came away and at about this time
hemorrhage recurred. Dr. Smythe happened to be in the hospital at
the time of the bleeding and was about to go hunting. He promptly
opened the wound and poured the contents of his bag of bird-shot
into it and put on a compress. Miraculously this procedure, plus
ligating the vertebral artery, controlled the hemorrhage. The
patient survived for eleven years, and then died by hemorrhage
from a recurrence of his subclavian aneurysm.[15][16]

Following Dr. Smyth's case, the next twelve ligations of the
innominate ended in death.

It was not until 1889, after the beginning of the aseptic era,
that a second patient had a long-term survival following ligature
of the innominate. The operation was performed by J. Lewtas while
in the British service in India. The patient was a twenty year-old
man, an Indian national, who had a traumatic aneurism of the right
subclavian artery secondary to a gunshot wound. The carotid and
innominate arteries were ligated. No infection occurred, the wound
healed by primary union, and the patient recovered. Mr. Lewtas
remarked in his report that he probably wouldn't have undertaken
the procedure if he had known how dangerous it was. Thereafter,
only four successful ligations were reported until after the turn
of the century when they became increasingly frequent.[17]

From Mott's operation in 1818 to the end of the century, only
Cooper reported having twice ligated the arteria innominata.[18]

We have already mentioned Cooper's one lasting contribution to the
procedure for ligating the innominate. He was the first to remove
the sternal end of the clavicle and a portion of the summit of the
sternum to gain adequate exposure for the removal of large and
complicated aneurysms. He wished to be remembered for this
significant innovation and made special mention of it in his
summation of each operation. In 1922 Dr. Emile Holman was the 88th
surgeon to ligate the innominate. The lesion was a very
complicated post-traumatic aneurism of the subclavian artery. He
was ultimately successful in extirpating the aneurism by gaining
the necessary exposure through the approach pioneered by Cooper
sixty-three earlier. When Dr. Holman performed this operation in
1922 he was a Resident Surgeon at Johns Hopkins Hospital. When he
later became Professor and Executive Head of the Department of
Surgery at Stanford Medical School in San Francisco from 1926 to
1955, he was, in effect, the linear successor of Professor Cooper.[19]

Cooper still lives in the annals of those who have performed
truly "great operations." But we have seen that these cases
brought him little acclaim and much criticism.

Ligation of the Carotids

The first experiment to be undertaken by Cooper after his
arrival in San Francisco took place in the fall of 1855, soon
after the organization of the Medico-Chirurgical Association. By
this time he had advertised his "Course of Medical Instruction"
which was to include "Experimental Surgery by Vivisections." He
had also set up a laboratory for animal surgery in his new
Infirmary at 14 Sansome Street and was prepared to inaugurate
experimental surgery on the Pacific Coast with an experiment on
the carotid arteries. He invited nine physicians, most of them
members of the Medico-Chirurgical Association, to witness the
event.

The question to be addressed by the inaugural experiment was
a minor one, but nevertheless of keen interest to the physicians
in attendance. The medical journals around the country had
recently carried a report by Professor Alex Fleming, M. B., of
Queen's College, Cork, Ireland, who claimed that pressure on the
carotid arteries so as to arrest the circulation in them would
cause anesthesia. Clearly, if such a simple procedure would serve
in lieu of ether or chloroform, it would be a boon to humanity.
Cooper doubted the claims of Professor Fleming but was loathe to
try the experiment on a patient. He therefore proposed instead to
ligate the carotids of a dog. While the witnesses watched
intently, Cooper deftly tied both the animal's carotids. Instead
of anesthesia, the procedure "produced only the slightest
immediate stupor that was but little increased at the end of one
hour."

Cooper concluded that, "I disproved (the claim of Professor
Fleming) by the above experiment to the entire satisfaction of all
present so far as I know." It is hoped that the demonstration at
least dissuaded the observers from trying Professor Fleming's
method in view of the possibility that, aside from not producing
anesthesia, compression of both carotids might cause stroke or
sudden death in the human subject. Cooper's modest first
experiment, which he never published, reveals the elementary state
of circulatory physiology in his day.[20]

Ligation of the Abdominal Aorta

In December 1855, soon after his experimental ligation of the
carotids, Cooper conducted a series of experiments involving
ligation of the abdominal aorta. We have already referred to these
experiments in Chapter 10 where we mentioned that, according to
Pancoast's Treatise on Operative Surgery[21] the abdominal aorta had been
ligated on only three occasions. In 1817 Sir Astley Paston Cooper,
Bart. (1768-1841) of Guy's Hospital, London, celebrated vascular
surgeon, was the first to ligate this vessel. He performed the
feat on a 38 year-old man who had a post-traumatic aneurysm of the
left iliac artery. The patient's death after forty hours was,
according to Sir Astley, "owing to the want of circulation in the
aneurysmal limb" which was "cold and lacking in sensibility." An
autopsy of the abdomen revealed no peritonitis and the aorta was
completely occluded by the ligature. The autopsy did not include
the chest.[22] In1829 Mr.
James of Exeter Hospital was the second to ligate the aorta. The
patient, who had an aneurism of the external iliac artery, lived
only three hours. No autopsy report or other details are available
to determine the cause of death.[23] In 1834 the third and last to
ligate the abdominal aorta prior to mid-century was Mr. John
Murray at the Cape of Good Hope. His patient was a Portuguese
seaman with a large aneurism of the right iliac artery. Following
the operation he developed numbness and paralysis of both legs and
died at the end of twenty-three hours with severe pain in the
lower extremities and the pubic area. There was no autopsy report.[24]

In addition to citing the above three cases of aortic ligation,
Pancoast made the following related observations:[25]

Since the attention of surgeons has been called to this
subject, more than forty cases have been reported of contraction
or accidental obliteration of the aorta from the pressure of
tumours or other causes, all of which tend to prove that
possibility, as before observed, of a return of the circulation
to the lower extremities after the obliteration of the lumbar
portion of this vessel. Upon these facts, in cases admitting of
no other chances of relief, has been founded the hope of success
in cutting down upon and tying this important trunk, rather than
upon the results of experiments on dogs, whose tenacity of life
surpasses that of man. In the three cases in which (the abdominal
aorta) has been tied in the living subject, the issue did not
justify the boldness of the proceeding, and it is very
questionable whether any case could occur that would fully
sanction the step.

Cooper was well acquainted with Pancoast's Treatise. The
accounts of failed aortic ligations, and of survival after gradual
occlusion of the vessel, so intrigued him that he decided to seek
answers to the following questions:

Why did the operated patients die so soon after
operation?

Is the cause of death preventable?

Surgical authorities had assumed that death after ligation
of the abdominal aorta would be caused by gangrene of the lower
extremities for want of sufficient circulation, or by peritonitis
or hemorrhage. Although deficient circulation to the legs was
documented in two of the operated cases, Cooper reasoned that
death occurred too rapidly for that to have been the sole cause of
fatality. Furthermore, neither peritonitis nor hemorrhage was
reported in any of the three patients. Thus, he argued, there was
another factor that contributed to the mortality of the procedure.

Rather than to eschew "experiments on dogs" as others had done,
Cooper proceeded with the following:[26]

Experiment 1. In order to eliminate the risk of
peritonitis, one of the three hypothetical causes of death after
ligation of the abdominal aorta, Cooper adopted the
retroperitoneal approach through the left flank used by Mr. John
Murray in his ligation of the aorta in 1834. This provided
excellent exposure of the abdominal aorta without entering the
peritoneal cavity. Meticulous surgical technique virtually
eliminated the danger of hemorrhage, the second presumed cause of
death. With these routine precautions, Cooper ligated the distal
abdominal aorta.

The animal died at the end of sixty hours, showing symptoms
of stupor after the first few hours. There was no peritonitis, no
hemorrhage, and no gangrene of the lower extremities to account
for the death. A similar operation was performed on a number of
animals with identical results.

Post mortem examination "in every instance showed the right
heart to be greatly distended with coagulated blood, and in many
cases to its utmost capacity, so much so, in fact, that the
distension equaled, if it did not even exceed, that produced by
the most complete injection of the heart, effected by
instruments, in making anatomical preparations. As this
coagulated condition of the blood and engorgement of the heart
was found to exist in every case, I was led to consider whether
it were not the chief cause of fatality, seeing that the coagulum
was formed prior to death, and whether cutting off nearly
one-half the entire vascular system, thus confining the blood to
so limited a capillary circulation, was the crucial factor. . ."

By his first experiment Cooper established engorgement of
the proximal arterial vascular bed as the cause of death after
acute ligation of the abdominal aorta in dogs. This finding
suggested that reduction of the engorgement was the key to
long-term survival after the procedure.

Experiment 2.. "In the second experiment I purposely
admitted of a free discharge of blood before ligating the
(abdominal aorta) upon the supposition that the loss of a
quantity of blood corresponding to the amount of the circulating
system cut off might remove the source of immediate death -
engorgement. This animal lived sixteen hours and a post mortem
examination revealed a similar condition of this as in the first,
except the large vessels were not so much engorged, the aorta
being almost entirely empty. But the heart on both sides was
perfectly engorged with blood to its utmost capacity, the blood
being coagulated completely. Abdominal viscera were healthy and
nothing untoward resulted from the local violence of the
operation."

Experiment 3.. "In order to produce an exact equilibrium in
the circulating fluid cut off by the operation and that remaining
undisturbed by it, I ligated the vein (inferior vena cava) in
connection with the aorta knowing that, whatever might be the ill
consequences of ligating a vein, that all other animals upon
which I had tried this experiment died long before this would
have interfered with the result. This animal lived about 16 hours
and from post mortem examination it was found that, while the
same amount of engorgement had not occurred in the heart as in
the other cases, still the coagulation was almost as complete
though not quite. The symptoms of stupor were the same as in the
other cases for the last eight hours preceding death.

Experiment 4. Having failed to prevent fatal excess of
engorgement by prior bleeding or simultaneous ligation of aorta
and vena cava, Cooper decided to diminish the circulation through
the aorta gradually as occurs in nature when the aorta is slowly
obliterated by tumor or other cause. For this purpose he exposed
the aorta and "applied a strap of leather lined by soft cotton
cloth around the artery and so compressed it as to arrest the
circulation through it principally but not so completely as to
render the pulsation of the iliacs imperceptible." This
tourniquet was brought out through the wound so that it could be
tightened from the outside, and the wound was closed around it.
On the seventh day of its application - the animal in the
meantime doing quite well - the tourniquet was tightened so as to
interrupt aortic circulation completely. "After the circulation
was thus entirely arrested in the aorta, there were no symptoms
of stupor, though this had been an early and constant attendant
upon all the cases in which I had operated previously. This dog
lived four days after the circulation was cut off from the lower
extremities through the natural channel, but died at last of
hemorrhage produced, as I supposed, by violent displacement of
the tourniquet with his teeth."

"The (tourniquet) was much larger than was absolutely
necessary as I could have an instrument constructed not over half
the size that would answer the purpose better in every respect. .
. I shall have one constructed and be ready to try it on the
human subject."

Conclusion. Gradual occlusion of the aorta in a dog
stimulated collateral circulation to the lower limbs, protecting
them from gangrene and the upper circulation from engorgement.

Cooper reported these experiments in a paper delivered at the
First session of the California State Medical Society in 1856. He
concluded the report by saying:[27]

I do not consider that this experiment has proven the
practicability of the process described, though it will have to
be confessed that a most important step has been made towards it,
seeing that every symptom of the animal was favorable until
hemorrhage supervened, and that in the human subject, nothing
would be easier than securing the vessel from violence offered by
the patient, and that nothing in human calculation could be
considered more certain than that the animal would have lived but
for the hemorrhage. . .

But the strongest evidence in favor of the practicability
of the operation for ligating the abdominal aorta, according to
the above detailed plan, remains to be given, and that is this,
viz., the circulation was restored, to a limited extent, in the
animal alluded to, by the reproduction of a small vessel passing
off from the terminus of the right (renal) artery and joining the
aorta below the place of ligating it, as is proven by a
preparation I made of the part, and fully injected, which I now
show you.

Cooper's experiments demonstrated two important points.
First, that early death after ligation of the distal aorta, at
least in dogs, may be caused by acute congestion of the heart and
proximal arterial circulation. Second that life-sustaining
expansion of the proximal and collateral circulation occurs
rapidly in response to gradual occlusion of the aorta, which
therefore becomes a feasible method of achieving is safe complete
ligation.

Following these experiments, had a patient with an aneurism of the
proximal iliac artery come under his care, Cooper would doubtless
have ligated the abdominal aorta after its gradual occlusion to
stimulate proximal and collateral circulatory adjustment, as was
done in his experiment. Unfortunately, It is also near certain
that infection at the site of ligation would have resulted in
sepsis and fatal secondary hemorrhage as in the innominate cases.
However, in the coming era of aseptic surgery, Cooper's approach
of stimulating collateral circulation by partial ligation prior to
later total occlusion might have been successful - and would have
been heralded as an historic surgical contribution. As an example
of the applicability of Cooper's method, the highly-regarded
vascular surgeon Harris B. Shumacker partially occluded the
innominate artery by banding it at an initial operation to reduce
flow, safely completing the occlusion at a later operation after
adequate collateral had been established in the upper extremity.[28]

Cooper could not have known that, some years before, Sir Astley
Cooper had ligated the abdominal aorta in two dogs. His purpose
was to identify the collateral pathways that would develop after
total occlusion of the vessel. Sir Astley reported his experiments
in a paper read before the Medical and Chirurgical Society of
London on 18 June 1811. In contrast to Elias Cooper's animals,
both of Sir Astley's dogs survived the ligation, showing only a
small degree of weakness in the hind legs. Post mortem injection
of the vascular system of these animals demonstrated a rich
network of anastomosing arteries circumventing the occluded site
in the aorta. It is unclear why Elias Cooper's animals all died
rapidly of cardiac and proximal arterial congestion after acute
ligation of the abdominal aorta while those of Sir Astley lived.
This outcome may have been due to the greater hardiness of the
British dogs, but it is also possible that Sir Astley's ligature
was tied more proximally on the aorta thus allowing for more
branches in the distal portion through which blood could return to
the lower limbs. There is insufficient information in his report
to allow us to settle the issue.[29]

Simultaneous Ligation of the Iliac Artery and Vein

Finally, we will refer again to the case of Frank Travers on whom
Cooper set out in December 1855 to ligate the iliac artery for
aneurism of the femoral artery. During the dissection of the iliac
artery, the iliac vein was torn. In order to control the severe
bleeding that followed, Cooper was forced to ligate the iliac vein
as well as the artery, a procedure thought to have dire
consequences. When Mr. Travers unexpectedly made a rapid and
complete recovery, Cooper wondered why. We discussed the case in
Chapter 8 and described the crucial animal experiments which led
him to conclude that, instead of having an adverse effect,
simultaneous ligation of the artery and its satellite or
accompanying vein slowed the venous runoff from the extremity,
resulting in a more balanced and physiologically effective
circulation.[30]

The experimental findings were unequivocal and compelling.
In five dogs the iliac artery alone was ligated. In every instance
the limb became cold and the sensibility was greatly diminished
for several days. In five dogs the iliac artery and vein were
ligated at the same time. In every instance the heat and
sensibility of the limb remained nearly natural from the first.

Cooper concluded that ". . .the advantages resulting from
the ligation of the satellite veins in connection with the
arteries which they accompany (are) clearly shown. . ."

Cooper's observation that simultaneous ligation of the major
artery and vein to an extremity had a beneficial effect was a
significant discovery. Since the period of John Hunter
(1728-1793), eminent surgeons had always stressed that the
greatest care should be taken, when tying a main artery, to avoid
all injury to the vein. In fact operative techniques for ligating
the artery were so devised as to minimize the risk of interrupting
the venous circulation.

Unfortunately, Cooper's important finding was essentially unknown
to the profession at large because of its publication in the
obscure California State Medical Journal which was discontinued
after four issues. Some half-century later, cumulative field
experience in the Boer War (1899-1902) and World War 1 (1914-1918)
showed that simultaneous ligation of artery and vein, made
necessary by wounds of both, was followed by a lesser incidence of
gangrene of the extremity than when the artery alone was tied.[31] This prompted the following
recommendation by the Inter-allied Conference of Surgeons held in
Paris in May, 1917:[32]

Contrary to what has until now been believed, simultaneous
ligature of both artery and vein when both vessels have been
wounded does not give rise to increased risks of gangrene; in
fact it diminishes them. Facts tend to prove, even when the wound
is limited to the artery, that simultaneous occlusion of the
unwounded vein is to be recommended.

After another decade, in March 1927, Emile Holman reported an
elegant series of simple yet definitive animal experiments from
which he also concluded that tying the vein as well as the artery
results in a more balanced circulation. "It would appear,
however," he added, "that ligation of the main vein should be
done, not at the level of the ligation of the artery, but proximal
to the venous tributaries that accompany the arterial branches
furnishing the main collateral circulation."[33]

How are we to assess these unique research efforts of Elias
Cooper whose laboratory investigations were undertaken with
limited resources in a hostile milieu far from the mainstreams of
medical science? Regrettably, his observations have hardly seen
the light of day because of the parochial and transient nature of
the California State Medical Journal in which he published.
Nevertheless, his contributions were original and memorable,
stamping him as the preeminent (and only) circulatory physiologist
of the western region for some years to come.

Cooper's vascular operations and circulatory studies have
previously received only passing mention in biographical sketches.
Therefore, we have thought it essential to provide a sufficient
account of his work to permit others to consider the significance
of his efforts, and accord them such recognition as they deserve
in the records of medical progress.

Clinical Investigations

In reading Cooper's papers, one is struck by the intuitive
common sense and independence of mind with which he approached
surgical problems. He constantly sought not merely to report cases
but also to improve surgical results by identifying and promoting
new surgical principles.

Anchylosis of Joints

For example, orthopedic conditions, that is, surgical diseases of
the bones and joints, constituted a major portion of Cooper's
practice throughout his career. As we have previously mentioned,
one of his earliest papers, published in 1852[34], was on anchylosis (fixation) of
the knee joint secondary to trauma or infection. He described the
successful treatment of this severe disability by having the
patient walk in an ingenious splint of his own invention. The
method described by Cooper led to gradual extension and
restoration of mobility in the joint with minimal discomfort. This
was an immense advance over the procedure sometimes employed of
forcibly wrenching the frozen joint apart under anesthesia in the
false hope that its function would be thereby improved. Cooper's
program presaged the later general adoption of the principles of
progressive joint mobilization combined with weight-bearing in the
rehabilitation of these cases. As a result of technological
advances inconceivable in the mid 1800's, such conditions can now
be treated by joint replacement.

Cooper published two additional papers on his method of managing
joint anchylosis in the lower extremities. He claimed originality
for the concept and the apparatus, and priority of publication on
the subject. His claim was questioned but no evidence was ever
brought forward to refute it. Since all three papers appeared in
the Transactions of medical societies, they had limited
circulation and Cooper therefore received scant recognition for a
significant innovation.[35][36]

Joint Infection and Air in Joints

Cooper's empirical style is further illustrated by his
approach to joint infection. From the beginning of time until the
discoveries of Pasteur and Lister, wound infection was a major
deterrent to surgical progress. The advent of anesthesia, by
broadening the scope of surgical interventions, actually served to
increase the adverse potential of postoperative septic
complications. Cooper's practice included many patients with
infections of bones and joints, anatomical sites where sepsis
tends to be exceptionally persistent and disabling. In his
perceptive and methodical fashion he began in 1859 a series of
observations and publications on the cause and management of
septic joints. He considered his work on this subject to be his
most important contribution in the field of clinical surgery, and
for that reason we will describe his findings and recommendations
in some detail.

Joints and their adjacent tendons are sheathed by synovial
membranes which secrete the synovial fluid that lubricates the
moving parts. The synovial membranes are highly vulnerable to
infection and the closed cavities they encompass are a fertile
site for the incubation and delayed invasion of even a tiny
inoculum of bacteria. In Cooper's day, the fact that infection is
caused by microorganisms was still unknown. It was, however,
common knowledge that small penetrating wounds into a joint such
as the knee were frequently followed by severe inflammation. It
was also observed that signs of inflammation were often delayed
for a week or more after the injury, by which time the original
wound may have completely healed.

It was widely, but not universally, believed (1) that these
puzzling events were caused by the entry of air into the joint at
the time of injury; (2) that air itself was harmful; and (3) that
its admission into joints should therefore be prevented. This
dictum was either supported, or not specifically contested, by
major surgical authorities on both sides of the Atlantic,
including such respected figures as Samuel D. Gross and Joseph
Pancoast in America, Richard Barwell in England, James Miller in
Edinburgh, and Dupuytren and J. Guerin in France.[37][38][39][40]

As examples of the advice from these eminent surgeons on the
importance of excluding air from joints, we quote the following
excerpts:

From the well-known Treatise on Operative Surgery, 1852, by
Professor Pancoast of Jefferson Medical School:

Hydrarthrosis of the Knee Joint. All therapeutic measures
having failed, after a thorough trial to cause a removal of the
dropsical accumulation, we may discharge it either by incision
with a bistoury, or puncture with a trocar. The great object in
the operation is to avoid the entry of air, which might provoke
irritation in the cavity of the joint, and give rise either to
suppurative inflammation of the serous membrane, or even
ulceration of the articular surfaces.

From the widely-used Principles of Surgery, 1856 edition, by
Professor James Miller of Edinburgh University:

Removal of Loose Cartilage from Knee Joint. The operation,
as we would advise it, is thus seen to consist of distinct parts.
1. The prophylactic preparation; occupying not less than several
days. 2. The oblique valvular puncture; carefully avoiding the
entrance of atmospheric air, even into the superficial areolar
tissue, etc.

On the other hand, such distinguished surgeons as James Symes in
England and Alf. A. L. M. Velpeau in France were opposed to the
doctrine of the harmfulness of air.[41][42]

Under the circumstances, It is fair to say that in Cooper's
time the effect of air on joints was an important unsettled issue
from the surgical viewpoint. Furthermore, no credible surgical
authority was taking a firm stand in the literature of the day
against the presumption that air was injurious to joints - that
is, there was no persistent dissenting voice until Cooper launched
his campaign on behalf of the harmlessness of air.

The theory that air caused inflammation in joints had serious
practical consequences. For fear of the noxious effects of the
atmosphere, there was a disastrous tendency to defer the prompt
and free opening of wounded joints at the earliest sign of
inflammation lest the entry of air would aggravate the condition.
Based on the same apprehension, the operation for removal of
floating cartilage in the knee was considered very dangerous
because of the frequent occurrence of postoperative joint sepsis,
presumably caused by the entry of air during the operation. To
prevent entry of air into the knee joint during such operations,
Gross, Pancoast, Miller and many other leading surgeons
recommended maneuvering the cartilage into a subcutaneous location
whenever possible and then removing it through a subcutaneous
tunnel or by cutting down on it directly. Dr. Toland appeared to
believe in the adverse effects of air and in 1858 reported two
cases of attempted airless removal of floating cartilage according
to the above technique. Nevertheless, both cases later required
incision and open drainage of suppurating wounds.[43]

In contrast, Cooper was thoroughly convinced that air was
innocuous to joints. He observed in his practice that:[44]

Large wounds, or those opening freely the knee joint, are
inclined to heal kindly by granulations, and if properly treated,
to result in a complete cure, while a small punctured wound which
heals on the external surface by first intention often, if not
generally, results in the highest possible grade of inflammation,
frequently passing rapidly into suppuration and destruction of
the joint, if not even of the life of the patient.

Cooper argued that the inflammation which develops following a
puncture wound is not caused by the minute amount of air admitted
at the time of the injury, as generally supposed, but by the
accumulation in the joint of "purulent matter" that could not
escape through the small wound. The grand mistake, he said, was
not in permitting air to be admitted into the joint, but in not
keeping the external wound sufficiently open to allow the free
discharge of serum and purulent matter. Groping vainly for the
mysterious source of the "purulent matter" that produced
inflammation in wounded joints, Cooper sought in the following
soliloquy to exonerate the atmosphere:[45]

I would challenge the most industrious or ingenious to show
by statistics, or any fixed physiological laws, why the mere
admission of air into the knee, or any other joint, would cause
inflammation. . . Many cases of dangerous symptoms, or of death,
are (reported), where air was admitted into joints, even in cases
of exceedingly slight wounds; but does that go to prove that air
did the mischief? Who has any direct evidence to bring up in
support of this hypothesis, further than that it is based upon
the long standing opinion of able men? What poisonous agent can
there be in the air that produces such destructive results as are
attributed to it, when admitted into wounds? And if there were an
indefinable something acting thus, why should it not show the
effect at once?

Consistent with his thesis that air is harmless to joints,
Cooper's procedure for the removal of floating cartilage from the
knee joint was to make an adequate incision into the joint for
good exposure, extract the cartilage under direct vision, and
either to pack the wound open for gradual healing by granulation
or, alternatively, to close it primarily with sutures. Whenever he
closed the wound, he was prepared to provide free drainage by
opening it widely again at once on the slightest evidence of
inflammation. This unorthodox approach, characteristic of Cooper's
independent thinking, was a radical departure from the convoluted
procedures designed to exclude air from the joint that were
recommended by Gross, Pancoast and Miller.[46][47]

In the four-year period from 1859 to 1862 Cooper engaged in
a veritable crusade (1) against the concept that air is harmful to
joints; (2) in favor of the prompt and wide opening of joints at
the earliest sign of sepsis; and (3) in support of his regime of
wound healing by granulation. During this period he published nine
papers on these subjects, seven in eastern journals and two in the
San Francisco Medical Press. In addition, he wrote ten
Commentaries in the Press along the same lines.

Concurrent with Cooper's observations on inflammation in
joints, historic developments were occurring in Europe. In 1860
Pasteur demonstrated bacteria in the air and showed that specific
microorganisms were responsible for specific biological processes,
including infection. He thus laid the foundation for the germ
theory of disease and paved the way for Lister to demonstrate the
control of surgical infection by antisepsis in 1867. These and
later findings have shown that Cooper's deduction regarding the
harmlessness of air per se was correct. Although the atmosphere
does contain some bacteria, air is not responsible for the
invasive sepsis that often follows closed wounds of joints.
Instead, the infection is caused by entry into the joint of
bacteria from the patient's skin and from whatever else makes
contact with the joint cavity including, in the preantiseptic era,
the unsterile hands and instruments of the surgeon.

Cooper's empirical conclusions regarding prevention and management
of joint sepsis were equally as astute as his views on air. He did
not hesitate to challenge traditional wisdom by vigorously
promoting what he designated as his New Surgical Principles:[49][50]

1st. That atmosphere, admitted into the joints or other
tissues, is not a source of irritation or injury, except where it
acts mechanically; as, when admitted into a vein, by producing
asphyxia; into the thoracic cavity, by its pressure producing
collapsing of the lungs, or when, by the long-continued exposure
of a large amount of surface of any of the internal organs, whose
normal temperature is much above that of the atmosphere, it
reduces it so as to produce a morbid action.

2nd. That the division of entire ligaments about the joints
is no impediment to their ultimate strength and mobility; but, on
the other hand, this operation will often greatly facilitate the
cure, by enabling the surgeon to open the affected part fully,
for the purpose of applying medicinal substances to the articular
surfaces, when these are ulcerated or otherwise diseased.

3rd. That the only true mode of treating ulcerations of
bone, however slight, within the joint, is to lay it open freely,
and apply remedial agents directly to the part affected.

4th. That opening the joints early, in case of matter
burrowing in them, is far more imperiously demanded than the
opening of other parts thus affected, and the operation produces
no further pain or inconvenience to the patient, in any respect,
than when performed on parts remote from joints.

5th. That after opening a large joint, the knee for
instance, by an incision several inches long, the wound should be
kept open by the introduction of lint (a soft, fleecy substance
consisting of either cotton or linen), or other similar material,
until the parts within the articulation become healthy, and, in
all cases, it should be made to heal by granulation.

6th. That extensive wounds, opening freely the large
joints, such as the knee, (even when lacerated, as by a saw,
which must necessarily heal by granulation), do not as often give
rise to violent symptoms as very small wounds, such as are made
by the corner of a hatchet, an adze, or a pen-knife, which heal
on the outside by first intention.

7th. That there are no known limits beyond which a tendon
will not or cannot be reproduced after division, provided the
parts are made to heal by granulation, and that the present
acknowledged rule of two inches being the maximum distance in
which the divided ends of a ligament or tendon can safely be
separated, has not the least foundation in fact.

Cooper proudly presented his New Surgical Principles as part of
his Report of the Committee on Surgery at the Sixth Annual Session
of the California State Medical Society in February 1861. As we
have already learned, there were only thirteen members present at
this, the last meeting of the original Society, and no
Transactions of the Session were ever published.[51]

Cooper's fifth Surgical Principle refers briefly to wound
healing, a subject of paramount importance in surgery. His
contribution in this area therefore deserves further comment. With
respect to wound healing, broadly speaking, both accidental and
surgically incised wounds heal either by first intention (the
edges of the wound are brought together and healing occurs rapidly
without suppuration) or by second intention (the wound is left
open, suppuration occurs and healing is by granulation). In the
pre-antiseptic era, because of the failure to prevent bacterial
contamination, accidental wounds that were closed by suture or
other means commonly suppurated, broke open and healed by
granulation. Wounds of major operations were also usually followed
by varying degrees of suppuration and the death rate from sepsis
was high. Cooper took special note of the fact that when
accidental and operative wounds were left open, suppuration was
minimized and invasive infection was rare. The resultant healing
was by second intention and was slower, but the morbidity and
mortality were less.

This observation was by no means original with Cooper, but he used
it as the basis for a specific routine for the handling of certain
wounds. The routine itself was also not strictly original, but it
did prescribe a particularly effective combination of methods in
common use. He repeatedly recommended it in many publications, and
specified the circumstances under which it should be used. The
following is a paraphrased outline of his regime as it appeared in
several publications:[52][53]

In all surgical incisions made for drainage of inflammation
in a joint or a bone, or for the treatment of a compound or
ununited fracture, the wound should be laid open freely and
packed with a piece of lint which is kept soaked with an
evaporating lotion composed of one part of alcohol and ten parts
of water (a mildly antiseptic solution). Thus the wound is made
to heal entirely by granulation. The packing is held in place by
a roller bandage wrapped around the limb from fingers to near the
axilla or from toes to upper thigh. The roller is applied as
tightly as the patient can conveniently bear in order to splint
the limb and prevent the burrowing of purulent matter among the
surrounding parts. After three to five days the evaporating
solution is discontinued and warm poultices are applied. The
roller and packing may be dispensed with at any time after the
poultices are begun, but should remain or be replaced as long as
necessary to support the limb and prevent the wound healing
otherwise than by granulating from the bottom.

Cooper's New Principles and his regime for the healing of
wounds by secondary intention, were sound guidelines for the
pre-antiseptic era. They had the merit of being thoroughly
validated in the course of his extensive practical experience with
bone and joint infections, of which he gave many examples in his
articles and commentaries.

Cooper was justifiably confident that no previous author had
been so concise and explicit with respect to the issues he
addressed.

He sought through the medical literature to reach a national
audience with his proposals. In order to determine the kind of
reception they received among the profession, he wrote a
commentary in the January 1861 issue of the San Francisco Medical
Press entitled, "We challenge criticism," in which he invited
others to criticize and refute his principles if they could.
Having for over six months received no response to the challenge,
he was pleased to think that his New Surgical Principles were
being recognized as an important and original contribution to the
problems of septic joints and wound healing.

However, late in 1861, the editor of the Philadelphia Medical
Reporter published the following editorial in which he questioned
the originality of Cooper's observations and recommendations:[54]

To Dr. Cooper, of San Francisco, is due the credit of
establishing the great advantage of free openings into
suppurating joints, and of illustrating, by extensive practice
the innocuousness of atmospheric air, when admitted into synovial
and serous cavities. Dr. Cooper is in error in supposing, as is
evident from a recent editorial in his journal, that the
treatment of disorganized joints by incision is not, to any
extent, adopted by surgeons. It has been, for some years,
practiced by many surgeons in this country, as by Pancoast,
Agnew, Morton, and others of this city; extensively by Bauer, of
Brooklyn, and Walter of Pittsburgh. We believe that the latter
named gentleman would dispute with Dr. Cooper the priority of the
practice. We have repeatedly, during the last two or three years,
relieved suffering and saved joints and limbs in the Philadelphia
Hospital, by free incisions into suppurating articulations. The
practice has also been, to some extent, adopted abroad, and we
have seen the subject favorably noticed in European journals,
with proper credit to Dr. Cooper.

While giving Dr. Cooper credit for really establishing the
advantage of this treatment, in an extensive number of cases, and
of being the author of its introduction as an established rule of
practice, any real originality in the treatment cannot be claimed
by him. It has been the practice of some surgeons, for a long
period, to occasionally open suppurating joints for the escape of
pus and the debris from the diseased articulating surface. If we
could take the time to look up the literature of the subject,
this assertion might be abundantly proved. The only case in
evidence to which we can, at present, refer Dr. Cooper, occurred
a long time ago, in the practice of Mr. Guy, of London, and is
recorded in an article by him in Braithwaite's Retrospect, part
xxiv., page 171.[55]

Cooper responded promptly to the editor of the Philadelphia
Medical Reporter by publishing the following extended reply in the
January 1862 issue of the San Francisco Medical Press:[56]

We do not claim to be the first who opened joints in a
state of suppuration. There are several cases reported in
standard works upon Surgery, but we know of no standard work in
which the practice is recommended as a rule. The cases mentioned
were generally regarded by the writers as exceptional ones.
Whereas, we believe that in all cases where purulent matter is
found, in any considerable extent, in a joint, it should be
discharged by a free incision, if such an operation would be
proper in the patient who has burrowing matter in any other part
of the body; and that the operation is more imperatively demanded
in the former than the latter case; and, further, that the more
complicated the joint (such as the knee) the more the operation
is demanded early.

Probably medical journalists have been led into the opinion
that we urged an exclusive claim to this practice, in consequence
of our articles upon the subject being generally accompanied with
remarks in regard to the innocuousness of atmosphere admitted
into the joint. Upon this subject we do claim priority. So far as
we know, there is not another writer, either as a standard author
or contributor to a medical journal, who claims to have any
convincing proofs that atmosphere admitted into joints or other
tissues is not generally a source of danger; on the other hand,
they all urge, when dwelling upon the subject, that it is a most
unfortunate, if not even a dangerous occurrence.

Although Pancoast occasionally practices opening the
joints, when purulent matter is found in them, this he must do
with misgivings as to the propriety of admitting air, if we are
to judge from what appears to have been his opinions at the time
of publishing his Operative Surgery. The most stringent
directions are given, in his article on Club Foot, not to permit
atmosphere to enter the wounds, in operations for dividing the
tendons.

We were not aware, prior to reading (the above editorial
from the Philadelphia Medical Reporter) that the plan of opening
the joints was so extensively practiced in the United States, and
do not know still whether the publication of our articles
(several years since) were not commenced previously to the time
this practice was so inaugurated. At least we have not seen the
reports of any of these cases until since that period.

So far as the interests of the profession are concerned,
the subject of priority is a small matter, in comparison with the
importance of the practice in question, and we consider it the
duty of all practitioners to report the results of their cases,
because the profession have not universally, nor even generally,
adopted it as yet. We hold that a practitioner owes no greater
obligation to the medical world than that of reporting his more
important cases. And, upon this subject, we would solicit
communications and the reports of cases, from practitioners of
this Coast, where the practice of opening suppurating joints
early is rapidly gaining ground.

We shall now conclude our discussion of the harmlessness of
air and the importance of early open drainage of suppuration in
joints. The advance of medicine since the mid 1800's has made
these and innumerable other medical questions of that day no
longer relevant. Nevertheless, they were highly significant at the
time and we should evaluate in context the contributions of a
tenacious pioneer like Cooper who, under adverse conditions,
probed the frontier of knowledge in search of answers to
contemporary issues.

The editor of the Philadelphia Medical Reporter did not
question the validity of Cooper's New Surgical Principles and
acknowledged his role in bringing them to the attention of the
profession on both sides of the Atlantic. We have seen that
medical myths and antique precepts such as Cooper attacked were
difficult to eradicate and there is no doubt that Cooper's crusade
was a significant blow to popular fictions regarding the treatment
of septic joints - a remarkable accomplishment for a beleaguered
surgeon at the nation's far western fringe.

It was especially gratifying to Cooper that his friend and editor
of the Chicago Medical Journal, Professor Daniel Brainard of Rush,
published a full list of New Surgical Principles and had a few
encouraging words about Cooper's campaign of enlightenment in the
following editorial:[57][58][59]

Free Openings into Suppurating Joints. There is very
decided progress in opinions with reference to the propriety of
freely opening synovial cavities, where evidences of suppuration
are present. The danger of admission of air has been clearly over
estimated. The advocates of speedy opening have, recently,
adduced powerful support of their position by published cases. .
. We opine that pure air is not so dangerous, either to the
internal or external parts of the body, as some . . seem to
imagine. The advantages of freedom of discharge largely
counterbalance all theoretical fancies about the disastrous
effects of air.

Professor Brainard's comments are interesting in that they
confirm Cooper's thesis that there was a widespread misconception
as to the proper treatment of suppurating joints and to the
effects of air. In fact, Brainard seems a little ambivalent on the
subject himself. His editorial is not exactly the ringing
endorsement of Cooper's position that one would expect from the
truly converted.

The only major surgeon to come forward to question Cooper's
priority in these matters was Dr. Lewis A. Sayre (1820-1900),
Professor of Orthopedic Surgery at Bellevue Hospital Medical
College in New York who has since been recognized as the founder
of modern orthopedics in America.[60] He informed Cooper in a letter of
1 March 1862 that he had taught the harmlessness of air in joints
"for the last eighteen years" and referred to an enclosed
"pamphlet" as proof. The pamphlet never arrived and Cooper invited
Dr. Sayre to send him any "published articles" on the subject that
he may have authored. Cooper reminded him that "Of course the
claim of priority will rest, as usual, upon the fact as to who
published first." We have no evidence that Dr. Sayre ever
responded.[61]

Based on the information we have in hand, it seems
reasonable to credit Cooper with priority in dispelling
widely-held false notions as to the effects of air on joints, and
in defining the proper management of suppurating joints. He
exposed current misunderstanding with respect to these subjects.
He brought his New Surgical Principles to the attention of the
medical profession in the United States and western Europe by
publishing his views repeatedly in respected medical journals,
marshalling abundant evidence gleaned from personal observations
in his own practice. As in the case of Dr. Holmes' impassioned
plea for the profession to avoid behavior known to be associated
with the spread of puerperal fever, Cooper's message was also
based on concepts and practices already in the "public domain."
His contribution, like that of Dr. Holmes, was to mount a vigorous
and persuasive advocacy which rescued valid methods from relative
obscurity and brought them into more general application. For this
single-minded and single-handed achievement, he deserves honorable
mention in the annals of surgery as a clinical investigator.

Nulla Dies Sine Linea

In concluding this review of the highlights of Cooper's
professional career, we return now to a consideration of the
precepts that gave such unwavering direction and driving force to
his endeavors. We earlier paid our respects to the wholesome and
supportive effect of his Quaker family background, and to the
further shaping of his character in the crucible of pioneer life
in the Old Northwest. To these influences we can attribute his
moral fiber and stoical outlook; acquisitive mind and independence
of opinion; and fierce intolerance of arrogance and deceit. We
have seen ample evidence of these elemental traits in the
preceding pages, but we have previously had little from Cooper
himself about the convictions he held, and could recommend to
others.

Cooper's papers include the manuscripts of a prodigious number of
surgical lectures. These were generally on clinical subjects but,
fortunately for our record, two of them were of a general nature,
devoted primarily to counseling the medical students. One was an
Introductory and the other a Valedictory Lecture. These addresses
were for Cooper a welcome opportunity not only to give fatherly
advice to the students, but also to express his own professional
philosophy.[62][63]

Introductory Lecture. Surgery is that branch of the healing
art which is frequently represented as practiced by the hand, and
many are disposed to apply the name of Surgeon to the mere
operator, though nothing could be further from the true and
practical acceptation of the term; for though no one can be
really an able surgeon and not a skillful operator, still one may
be a beautiful operator and not be a skillful surgeon; and a
wide-spread, but temporary reputation is frequently acquired by
one quality alone. Thus brilliant and bold operators frequently
obtain renown very rapidly for daring operations, more
particularly when they attempt those which have been denounced by
others as impracticable. But sooner or later the genuine Surgeon,
as well as the mere operator, will stand upon his true merits.
Medical men take up this matter and pronounce a true verdict, not
always true at first, but eventually so. Prejudice, jealousy, and
many other causes may prevent the Surgeon from obtaining justice
during life, but posterity will be sure to award him his due, and
to the man of great soul this is a happy thought. . .

I wish now to occupy your time during a brief period for
the purpose of considering matters more directly connected with
the medical course we are about to enter upon; a course which, if
properly conducted on the part of both teacher and pupils, must
redound to the great good of all; but a course which cannot be
properly conducted on the part of any without great industry and
punctuality in attending to our respective duties. And in
practicing industry, I do not only wish you to study and think
industriously, but I wish you to act. Always let your knowledge
be based upon experience as far as possible, and your experience
based upon your own actions or observations. . .

There is no doubt but that Aristotle was one of the
greatest philosophers and logicians the world ever produced. It
is extremely probable, in my estimation, that he was really the
greatest man in these respects that ever lived. . . Why was his
philosophy more correct and his logic more powerful than any
other? Because his philosophy was based upon actual experiments
and his logic upon experience. What was old in philosophy he
submitted to the test of experiment before either condemning or
approving, and what was not known he tried to know by the same
method; consequently his system of philosophy was composed solely
of knowledge - not theory - and as facts and principles do not
change with the changes of men's minds in regard to them,
Aristotle's views are found to be more and more correct as ages
advance and men are capable of comprehending them.

Nothing is really valuable in medicine which is not based
upon experience, and nothing is so important to a medical student
as a collection of those facts and principles which enable him
early to obtain knowledge by experience.

In a profession still permeated by the dogmas of arcane
medical "systems," and reliant on traditional remedies and
methods, Cooper's advocacy of critical observation and experiment
was in the vanguard of the modern era. On a personal level, he
revealed his hope that he will be remembered as more than a "mere
operator;" and that posterity will rebuke the prejudices and
jealousies under which he labored by awarding him the laurels of a
True Surgeon.

Valedictory Lecture: Labor and its Results. The most
frequent cause of difference in the reputation of medical men is
the difference in their habits and course of life. Men whose
reputation places them far above their fellows are often by
nature scarcely equal to those by whom they are surrounded in
early life. But day by day and year by year they widen the
distance between themselves and their associates until the one
enrolls his name in the galaxy of great men, perhaps authors, and
fills a continent, possibly the civilized world, with his fame.
The others are only known within the precincts of their
respective residences as moderate practitioners while a
retrospective glance at life may in all probability show the very
interesting fact that these men were side by side in the same
class, acquitted themselves equally well in the same quiz - the
man of reputation answered his questions no worse and yet no
better than the one who is now obscure, while a true prophetic
glance at life could have equally astonished both.

Was there indeed so great a difference in these men by
nature so hidden that not only common observation but even the
ordeal of quiz failed to detect it?

You anticipate my answer - there was not. What was then the
source of so great a dissimilarity in the destiny of these men?
This becomes a question not only interesting but important to be
solved because its solution gives courage to the patient,
energetic and constant laborer in our profession, and proves to
him that his reward is sure; while to the one of contrary habits
it but too plainly shows him that, without a change of his
course, he is sooner or later to be outstripped and probably by
one whom he would assume to regard as his inferior.

The whole secret of the difference is this - the one had a
fixed object in view and never lost sight of it but labored day
by day and year by year for its accomplishment, while continued
pursuit (of excellence) gave vigor of intellect as well as
confidence of success. By becoming every day more assured of his
competency to compete with others, he received constantly
accumulating evidence of final success, and daily encouragement
to persevere.

He who like the Painter Apelles permits no day to pass
without its mark - Nulla Dies Sine Linea - no time to elapse
without a vigorous and well-defined effort to further the
accomplishment of a great work in life, (shall attain) all the
honors due his industry and perseverance. . .

Cooper was a tireless worker with the initiative and capacity,
unprecedented in the Far West of his day, to acquire new clinical
knowledge through observation and experiment. Thus he himself
exemplified the conduct and principles he sketched in these
lectures We may therefore accept them as a fair summation of his
personal creed. In simpler terms, we can say that he subscribed to
the contrived Latin adage - Labor vincit omnia.[64]

A Private Life

Conflict and acrimonious exchanges were such a prominent feature
of Cooper's professional relationships in both Peoria and San
Francisco that recounting his misadventures as we have done tends
to portray him as contentious and disdainful of the accepted
standards of medical ethics - which indeed he was. However, there
was a more appealing side to his nature. When a powerful cabal of
San Francisco physicians mounted an unscrupulous attack on his
integrity and surgical competence, his spirited defense and
demonstration of exceptional ability earned him increasing respect
and support from the local profession. The tide of opinion began
to turn in his favor at the Third Annual Session of the California
State Society in 1858 when he angrily accosted one of his
adversaries, Dr. Henry Gray, in the presence of Dr. Washington
Ayer and others. It is to the reminiscences of the fair-minded Dr.
Ayer, who became the first Dean of Toland Medical School, that we
now turn for a balanced appraisal of Cooper's true character:[65]

He was remarkably easy and plain, yet earnest in his
conversation - using terse, Saxon language to express his ideas,
and if at times, in the accommodation of necessities, he seemed a
little over-earnest, the occasion made his course pardonable. . .

While he could not be considered convivial, he enjoyed a
wholesome repartee, and found no pleasure in seclusion; was
always social without being familiar. He held no malice toward
any one, and with a mind conscious of rectitude feared no harm
from others. . .

He was a true friend, and by his life showed that he held
friendship too sacred to be even exposed to suspicion, and no
idle rumor of any change in affairs could change him or alter his
devotion to his friends. He was a man of thought, ever on the qui
vive, and ready to adopt new plans to new emergencies, and to
this quality of mind may largely be attributed his success. If
our colleges could give birth to more spirits like his, the world
would be wiser, and the profession more highly honored. . .

While I do not intend to say anything in such extravagant
words as might possibly be construed into an apotheosis, I must
admit that language seems quite inadequate to express fitly the
sentiments of lofty nobility of (his) character, energy, moral
excellence, and sturdy manhood. . .

Residence

Cooper's papers include little reference to his personal
affairs. Even about his places of residence in San Francisco we
have scant knowledge. We recall that upon his arrival in the city
in May 1855 he took accommodations at the Rassette House on
Sansome Street. When and where he moved from there, we do not
know. The next relevant information is found in an ad he published
in 1859 to which we have already referred. The ad announced that
"the state of his health has induced him to transfer his lodgings
to Oakland (ten miles across the Bay) where he will treat a
limited number of cases." How long he commuted to Oakland is
unknown.

The last mention of a residence among his personal papers is found
in his financial records where an entry indicates that he lived at
The Hotel International in 1860-62. This elegant five-story,
fireproof hotel, located on Jackson Street between Montgomery and
Kearny, was the elite place to stay from 1854.[66]

Irrespective of outside arrangements, Cooper doubtless also
maintained living quarters in the Pacific Clinical Infirmary. In
fact, an obituary published in the San Francisco Daily Alta
California on 14 October 1862 stated simply that he died "at his
residence on Mission Street." This could have been none other than
the Infirmary.

Since Cooper was unmarried and did not maintain a household,
paucity of information regarding his residence and private life is
perhaps not unexpected. Nevertheless we have diligently, but
unsuccessfully, sought for information about his personal affairs
in order better to understand how he coped with what must have
been a lonely private life, plagued by enemies and the shadow of
encroaching illness. Alone and beset, that is, until the arrival
of Levi Cooper Lane in the spring of 1861 to take up the position
of Professor of Physiology in the Medical Department. One can
scarcely overestimate the relief and reassurance that Lane's
devoted presence must have afforded the ailing Cooper.[67][68]

Financial Affairs and a "Shape of Ice"

Cooper was disciplined and industrious. However, in
comparison with his main competitor, Dr. Toland, Cooper's practice
was considerably less rewarding. His expenses included the
operation of the Pacific Clinical Infirmary, publication of the
San Francisco Medical Press, and the cost of his lodging and other
personal needs. These expenditures were met by income from the
Infirmary and, chiefly, by receipts from his surgical practice.

Cooper's annual gross income from practice was:

1859 $ 7300

1860 $ 8200

1861 $ 8900

1862 $ 2000

As we shall later see, at the time of his death, the total
value of Cooper's estate was only $8,500.

On the other hand, Dr. Toland's practice income was
phenomenal. By 1860 it had reached $ 40,000 a year, further
augmented by the profits from his thirteen thousand acre ranch in
the rich bottom lands of the Sacramento River. Toland was 54 in
1860 and in October of that year he married for the third time.
His fame and fortune were secure, yet he was nevertheless
dissatisfied with the state of affairs in the medical community.
As he saw it, the standards and good name of the local profession,
of which he was a pillar, had been compromised. The presumptuous
and incorrigible Cooper had established a medical school in spite
of the opposition of the old guard who had nothing but contempt
for the adventure. To make the enterprise even more offensive to
Toland, Beverly Cole was Dean of the Faculty.

Toland had never before shown the slightest inclination to teach.
But now he was determined to extinguish this unworthy and
unnecessary medical school (Wooster: "A Medical College was not
yet needed here.") by supplanting it with one of his own. Would it
be too harsh to attribute his new-found interest in medical
education to mixed motives of vanity and vengeance?[69]

It was early in 1860 that Cooper first heard rumors of Toland's
plan to found a second medical school in San Francisco, and wrote
that he welcomed the competition. Yet even as he issued this
generous challenge, Cooper could feel the chill from the looming
"Shape of Ice" just off the bow of the frail vessel he had
launched with hope and pride but two years before.[70]

Well: while was fashioning This creature of cleaving wing,
The Immanent Will that stirs and urges everything,

Prepared a sinister mate For her - so gaily great -
A Shape of Ice, for the time far and desolate.

And as the smart ship grew In stature, grace and hue
In shadowy silent distance grew the Iceberg too. . .

Valentine Mott , "Reflections on
securing in a ligature the arteria innominata: to which is added,
a case in which this artery was tied by a surgical operation,"
New York Medical and Surgical Register, vol. 1 (1818): p. 9, and
A. Scott Earle , Surgery in America: From the Colonial Era to the
Twentieth Century: Selected Writings (Philadelphia and London: W.
B. Saunders Company, 1965), pp. 96-118 Lane
Library catalog record, Lane
Library catalog record

Emile Holman , "Surgery of the large
arteries with report of a case of ligation of the innominate
artery for varicose aneurysm of the subclavian vessel," Annals of
Surgery 85, no. 2 (1927 Feb): 173-184

Astley Cooper , "Dissection of a limb
on which the operation for popliteal aneurism had been
performed," Medico-Chirurgical Transactions (published by the
Medical and Chirurgical Society of London) 2 (1813): 260-261 Lane
Library catalog record

Elias S. Cooper , "On the satellite
veins in connexion with the arteries which they accompany:
Operation of ligating the external iliac artery and vein; Rapid
recovery of the patient" (A paper read before the Second Session
of California State Medical Society, 11-13 February 1857)
California State Medical Journal 2, no. 2 (1857 Apr): 441-445 Lane
Library catalog record

George H. Makins , On Gunshot Injuries
to the Blood-Vessels: Founded on Experience Gained in France
during the Great War, 1914-1918 (Bristol: John Wright and Sons,
LTD., 1919), pp. 103-104 Lane
Library catalog record

Emile Holman , "Surgery of the large
arteries with report of a case of ligation of the innominate
artery for varicose aneurysm of the subclavian vessel," Annals of
Surgery 85, no. 2 (Feb 1927): 176-177

Elias S. Cooper , "Walking rendered
the primary element in the cure of deformities of the lower
extremities; its early adaptation to white swelling and coxalgia,
with apparatus for carrying out the designs of the same,"
Transactions, Illinois State Medical Society, 6-7 June 1854
(Chicago: J. F. Ballantyne, Printer and Publisher, 1854), pp.
39-54. Also based on material held at the Illinois State Medical
Society. Lane
Library catalog record

Elias S. Cooper , "Deformities of the
locomotive apparatus," (Annual address of the President of the
California State Medical Society delivered February 12th, 1857,
by the 1st Vice President, E. S. Cooper, A. M., M. D., of San
Francisco.) Transactions, Second Session of the Medical Society
of the State of California, 11-13 February 1857, pp. 17-22

Elias S. Cooper , "On the removal of
floating cartilages from the knee joint, by a free incision; with
remarks upon the admission of air into wounds of the joints in
general," Cincinnati Lancet and Observer 2, no. 12 (Dec 1859):
724 Lane
Library catalog record

Elias S. Cooper , "On the removal of
floating cartilages from the knee joint, by a free incision; with
remarks upon the admission of air into wounds of the joints in
general," Cincinnati Lancet and Observer 2, no. 12 (1859 Dec):
725 Lane
Library catalog record

John Gay, Esq. , Surgeon to the Royal
Free Hospital, "Case of disease of the elbow joint," Retrospect
of Medicine (Edited. by W. Braithwaite) 24 (Jul-Dec 1851):
212-214. No article by a Mr. Guy, as referenced by the editor of
the Philadelphia Medical Reporter, could not be located on p. 171
of volume 24 of the Retrospect. However, volume 24 of the
Retrospect contains the here- cited article by a Mr. John Gay. He
describes his practice of free and open drainage of septic joints
and reports his successful use of the procedure on a chronic
infection of the elbow joint. Lane
Library catalog record